This section highlights a debate between Dr. Dino Spaniolas (Associate Professor of Surgery at Stony Brook University, New York, USA ) and Dr. Hayssam Fawal (Clinical Assistant Professor of Surgery, Beirut, Lebanon). Dr. Spaniolas will be representing the RYGB and Dr. Fawal the MGB/OAGB side. The expert opinion is by Dr. Jason Wong (Specialist Laparoscopic General and Bariatric Surgeon at Weight and Metabolic Solutions, Australia).
1. When is RYGB your preferred procedure? What are your indications? What are your contraindications?
Patients suffering from significant GERD may be best served with RYGB (Peterli JAMA 2018, Robert Lancet 2019). In particular, patients with Barrett’s esophagus, more so long-segment, respond best to this type of surgery (Andrew Surg Endosc 2018, Csendes Surgery 2006). Patients with history of cigarette smoking, or need for chronic NSAID use, I often warn against RYGB.
2. What are the expected results with weight loss, comorbidity resolution and long term outcomes in RYGB patients?
30-35% total weight loss (Courcoulas JAMA Surg 2018, Peterli JAMA 2018, Salminen JAMA 2018). Diabetes remission at 5-7 years is 45-60%.
3. What is the safety profile of RYGB (incidence of acute and long term complications)?
Based on audited clinical data, RYGB has 8% early complication rate (Kumar et al, Surg Obes Relat Dis 2018). Nutritional deficiencies (variable, Lupoli World J Diabetes 2017, Weng BMJ Open 2013), internal hernias (rate 1-3%, Geubbels Br J Surg 2015), and marginal ulcers can be long-term risks (rate 8% at 5 years, Spaniolas JAMA Surg 2018; 0.6% rate for reoperation for ulcer, Pyke Surg Endosc 2018). Thanks to accreditation systems and other registries, RYGB risks cannot be hidden. We should be embracing opportunities to learn from differential outcomes - good and bad - of different procedures, as a way to advance the field.
4. Why do you think MGB/OAGB is not as good of a surgery? What are your main worries?
OAGB could be a great option for many patients. For sake of the debate, I will expand to possible concerns:
a. Reimbursement. My main (and only real) concern with this procedure is reimbursement. This is not an insurance covered benefit for my patient population.
b. Malabsorption: Nutritional deficiencies, diarrhea and anemia (with a 200+ cm limb) is an issue, and this is acknowledged by OAGB surgeons (Robert Lancet 2019).
c. Bile reflux: Bilious GERD is seen after OAGB (Doulami Surg Obes Relat Dis 2018, Robert Lancet 2019). Fortunately, this is not a common occurrence (2% conversion to RYGB).
d. Which one? There is still uncertainty about branding, pouch, location and size of anastomosis, length or percentage of limbs. Similar details may exist for RYGB, but for the most part, they do not define the operation. Which one is the right OAGB?
5. Does RYGB address those worries you have with MGB/OAGB?
Yes, in terms of reimbursement and malabsorption (Mahawar Obes Surg 2017). The progress the bariatric community has made in terms of demonstrating value (weight loss, comorbidity improvement, cardiovascular risks, longevity) to patients, medical societies and insurance companies is based on high quality research. All those studies included RYGB, and not OAGB (Pories Ann Surg 1995, Rubino Diabetes Care 2016, Schauer NEJM 2014, Sjostrom NEJM 2007, Adams NEJM 2007).
6. Does internal hernia risk and bowel ischemia make RYGB a “scarier” operation when compared to MGB/OAGB?
The risk of internal hernia is present (evidently less) with OAGB. A patient after an intestinal bypass with severe abdominal complaints raises the same concerns, requiring the same management, despite difference in hernia rate.
7. What about incidence of diabetes relapse as well as weight regain, does that make you more cautious about offering RYGB?
Duodenal switch is an established insurance-approved more potent option than RYGB. Despite this, it is not commonly performed. Patients and surgeons are reluctant to offer such malabsorptive options, because of nutritional consequences. OAGB risks having the same fate, unless more credible data proves it otherwise.
8. RY surgeons are now increasing BP lengths in an attempt to match MGB/OAGB outcomes, why not just shift to MGB/OAGB?
I am not aware of any evidence to support a trend that surgeons are trying to make primary RYGB look like OAGB. There is evidence of distalizing RYGB for patients with weight regain to introduce more malabsorption, with associated downsides (Shin Obes Surg 2018, Ghiassi Surg Obes Relat Dis 2018). That seems less complicated than conversion to OAGB.
1. When is MGB/OAGB your preferred procedure? What are your indications? What are your contraindications?
OAGB is my choice for patients with BMI >45 , for revisional cases and patients with metabolic syndrome with lower BMI's. If we look at the outcome of sleeve gastrectomy for patients with BMI<45 that is almost double when compared to patients with BMI>45 (H Aridi, B.Safadi SOARD Nov 2016) at 5 years; we conclude that for such BMI's, sleeve may be not the best bariatric procedure. Restriction alone will most probably fail on the long term follow up. This is why I offer OAGB for BMI>45 as a first choice. For revisional cases and metabolic syndrome, a lot of data showed superiority of OAGB over sleeve and RYGBP. (Weiner Obesity Facts 2011, Lee Obes Surg 2018). As for the contraindication, I believe is severe reflux (Grade B esophagitis) is a reason no to do OAGB although no clear data till present
2. What are the expected results with weight loss, comorbidity resolution and long term outcomes in MGB/OAGB patients? What is the safety profile of MGB/OAGB?
Most of the long term data published on 5 and 10 years follow up showed EWL> 70 %, metabolic syndrome control > 75 % with early complications <3 % and long term complications<6 % including bile reflux, and protein deficiencies of which 0.8 % required re operation. (Taha Obes Surg 2017, Lee Obes Surg 2012)
3. Why do you think RYGB is not as good of a surgery? What are your main worries?
I have no doubt that RYBG remains till present one of the most studied procedures but these are my concerns on RY:
a. EWL after 5 years is slightly superior to LSG even less in other studies with significant more long term complications when compared to other bariatric procedures
specially internal hernias that vary from 2 to 6% in most of the series.
b. Starting now having longer BP limb in RY may raise the concerns on long term nutritional deficiencies even with measurement of total small bowel length.
c. Most of the data showed that 25 % of our bariatric procedures may need revision after 10 years. we all agree that revising RY is not a nice journey. added to this the outcome of revision is disappointing (bands, sleeve or distalization) and carry significant morbidities.
I believe in RYGB for BMI 35-45 with reflux as the standard of care.
4. Does MGB/OAGB address those worries you have with RYGB?
OAGB proved its safety and efficacy on long term , nevertheless the issue of bile reflux and nutritional deficiencies should be highlighted in OAGB studies( Baig SG, K.Mahawar;Obes Surg Feb 2019). Internal hernias are present but definitely less then RY (large Peterson’s defect in OAGB versus a smaller Peterson’s and mesenteric defects in RY). To add, revising or reversing OAGB is easier than revising or reversing RYGB.
5. If bile reflux was proven to increase risk of esophageal cancer in MGB/OAGB patients, would you stop performing MGB/OAGB and offer RYGB instead?
If data showed increase risk of harmful bile reflux with secondary cancer, I would question OAGB; few case reports till present (Aggarwal J Minimal Access Surg 2019).
6. What about incidence of long term nutritional deficiencies, does that make you more cautious about offering MGB/OAGB?
Standardization of BP limb length is essential to avoid nutritional deficiencies. Note that after 55 years of RY, we still do not know what is the ideal BP limb length and common channel length. This is what happening now with OAGB; nevertheless, after the work of Jean Marc Chevalier that showed that 150 cm for primary procedures may be enough with almost absent nutritional deficiencies, we may be able to build on this BP limb to avoid major nutritional problems .
7. Is it true that surgeons may choose MGB/OAGB since it is less technically demanding?
One of the important factors of having a successful bariatric procedure its easy reproducibility. Sleeve gastrectomy is now the most common procedure done in the US (>50%). This does not mean that this is the ideal procedure until we have long term data on safety and efficacy. Same applies to OAGB; its wide spread worldwide proves that it is reproducible . Long term data showed great efficacy that is superior to sleeve and RYGB. If long term data on bile reflux and nutritional deficiencies does not show a major concern in OAGB, I am sure that OAGB will replace RYGB in the coming 15 years.
The ongoing debate comparing RYGB and OAGB continues to be topical, when actually the recommendations for each procedure are not entirely the same. RYGB is a preferred option for patients with GERD or Barrett’s metaplasia, whereas OAGB is favored for higher BMI patients, as a sleeve revision option or for patients with metabolic syndrome. Both procedures have good results overall with weight loss for OAGB seemingly superior to the traditional RYGB with a short biliopancreatic (BP) limb, and both having acceptably low and comparable early and late complication rates. Concerns regarding RYGB include internal hernia, weight-loss only being slightly superior to sleeve gastrectomy and difficult revision options. Concerns regarding OAGB include reimbursement and recognition by health insurance, nutritional deficiencies and bile reflux.
Heterogeneity exists for both RYGB and OAGB techniques, with variations in both techniques regarding pouch length, anastomosis construction and most importantly BP limb length. The BP limb length remains a technical variable amongst both RYGB and OAGB surgeons worldwide, for which the ideal length is still unknown. It appears that a BP limb length of 150cm in OAGB almost eliminates nutritional deficiencies. RYGB surgeons who lengthen BP limb length in order to enhance weight-loss and metabolic control without measuring total small bowel length may potentially encounter problems with malnutrition if total small bowel length is short. The outcomes may also vary between populations due to dietary differences, pouch size and total small bowel length. There is no reason for OAGB not to be accepted as a mainstream bariatric procedure, likewise there is no reason that it will replace RYGB. The indications for each procedure are not exactly the same and it does not make sense to compare the two procedures that one is better than the other. Whilst some patients may be suitable for either procedure, this should be individualized for each patient and based on surgeon experience.
What needs to be accepted is that for both RYGB and OAGB, there will always be technical variations that may give heterogeneous results. These variations should not mean that a procedure cannot be named a certain way or that it is not equivalent. The mentality in which a surgeon thinks that their particular technique is the only way to perform a procedure, is certainly outdated and prevents collaboration, progress, and most of all leads to factions amongst those dedicated to the field of obesity surgery.
To conclude, OAGB should have a role in the bariatric surgeon’s armamentarium to be considered over sleeve gastrectomy for patients with a higher BMI or metabolic syndrome. RYGB remains an excellent option for patients with GORD, Barrett’s or where concerns exist regarding malnutrition or bile reflux.
Dr. Dino Spaniolas
Dr. Hayssam Fawal
Dr. Jason Wong
Associate Professor of Surgery at Stony Brook University, New York, USA
Clinical Assistant Professor of Surgery, Beirut, Lebanon
Specialist Laparoscopic General and Bariatric Surgeon at Weight and Metabolic Solutions, Australia
Post by: Dr. Ramana Balasubramaniam Commentary by: Dr. Hasan Jalamneh
Not too long back, I saw an elderly lady who had esophageal cancer operated 25 years back by a surgeon I knew. I was astonished. I checked and rechecked her notes, but yes, it was true. A muscle invasive esophageal cancer treated by surgery resulted in a cure, belying a common belief that these are bad cancers and patients die in a few months. So can that happen in hernia surgery with zero recurrences and in sleeve gastrectomy with zero leaks? I am genuinely interested in this question and so asked IBC members about their experiences. I also had read a paper by Warner (who, I think, is an Australian) who had zero leaks in 1070 patients. Warner makes the case for not doing a full posterior dissection and for not dividing the vessels going towards the uppermost part of the stomach. I wanted to find out if the dude sleevers were following this nugget of technical wisdom. So I asked this question in our IBC Facebook group. Most people where amused at the concept of zero leak. The only surgeon who can honestly claim a zero leak is the one who does not do a sleeve gastrectomy, as Eric Pauli claimed. But some surgeons like Hasan Jalamneh from Jordan were clearly being honest in talking about their astonishingly low leak rates, along other complications. Common refrains amongst the accomplished sleeve surgeons included: 1. Not twisting the sleeve 2. Not hugging the bougie 3. Staying away from the GE junction 4. Reinforcing the uppermost part of the staple line 5. Keeping a straight staple line There was unanimity in performing a full posterior detachment of the stomach. Some surgeons claimed a greater vulnerability in specific brands of staplers. So at the end of what was an energetic and long discussion, where do we stand on the subject? Did I learn any technical pearls that would assuredly prevent me from having a leak over the next year or two? Sadly, no. I will finish with this quote of mine: "Funds lie in fundus. If the fundus leaks, funds leak and fun leaks, so there's no fun in no fundus." So, my friends, stay away from that esophagus!
IS ZERO LEAK POSSIBLE IN SLEEVE GASTRECTOMY ? Absolutely not ... Not because it cannot be achieved, but because there are two humans in the equation, the patient and the surgeon. Among many points mentioned how to decrease incidence of leak, which most of them are correct, I find that after having all of them set to the right limits, surgeon muscles will still occasionally fail to execute what brain wants to do! This happens because of so many reasons which are related to our innate imperfection nature. Here is an example, while looking to the final shape of the sleeve tube I not very infrequently discover that I was too close to incisura, or the two leaflets of the sleeve tube are not equal or that I was too close to GEJ because I removed the pad of fat and have failed to keep memorizing this point when I placed the last firing . Why does that happen? Because we can get distracted by elements of surrounding environment . We might at any point experience visual misconception created by the limited two dimension nature of our laparoscopy systems or simply because we intentionally mean to modify our techniques after one patient has been reported he failed to achieve results we are expecting of the way we do sleeve gastrectomy. Luckily we most of the times escape with our imperfections but every one of us has to be aware this will not last forever. On the other hand, odds to have leak increase when the other human body in the equation unexpectedly reacts in a different way. One common example in my practice is that a certain bleeding spot which I am sure I have controlled decides “it was not controlled very well” . Patient will then have bleeding, which very well likely, is not manifesting clinically . Blood near stapler line will always be source of potential infection and hence a leak . This type of leaks and not the ischemic type I believe is the leak more likely to happen with the most experienced surgeon. Consequently, I paradoxically evolved with time from never leaving a drain to having very low threshold to leave a drain overnight. Obviously enough, this drain is not meant to uncover trivial bleedings that do not cause hemodynamic disturbances, it is rather meant to wash out the tinniest amount of blood near the stapler line. Finally, leak rate has always to be correlated with percentage of weight loss, as surgeon can play it very safely in regard to leak prevention precautions and fashion a very relaxed low pressure sleeve tube but he surely fails to produce the required restriction which will ensure good results of this operation . In brief, it is not true that leak happens because we don’t know or stick to the rules, it rather happens because we are doomed to fail to replicate the very same rules every time with the same efficiency we usually do.
Dr. Ramana Balasubramaniam
Dr. Hasan Jalamneh
Bariatric and AWR Surgeon,
Apollo Gleneagles Hospital,
Bariatrics and Laparoscopy Consultant.
Istishari Hospital, A
This retrospective review of 171 patients in a single center in USA by three bariatric surgeons over 4 years duration compares the two commonly used technique for gastrojejunostomy in RYGB: linear stapler technique or circular stapler technique. Both the groups were comparable in terms of basic patient demographics. The rate of surgical site infection was significantly higher in the circular stapled anastomosis group. Not surprisingly the rate of anastomotic stricture was higher in the circular stapled gastrojejunostomy group compared to the linear stapled group. Also, the number of dilatations required to treat the stenosis were higher in the circular stapled group compared to the other group. They conclude that they now routinely use linear stapled technique for their gastrojejunostomy in RYGB since this review.
Barr, A. C., Lak, K. L., Helm, M. C., Kindel, T. L., Higgins, R. M., & Gould, J. C. (2019). Linear vs. circular-stapled gastrojejunostomy in Roux-en-Y gastric bypass. Surgical endoscopy.
An interview with the corresponding author of the above publication, Professor Jon Gould (Professor and Chief, General Surgery; Alonzo P. Walker Professor in General Surgery, Medical College of Wisconsin, USA)
1- How does your study help finalize the comparison between those techniques?
I think there is a lot of published data supporting our conclusion that the stenosis rate is higher with a circular stapled gastrojejunostomy (CSA) compared to a linear stapled anastomosis (LSA). As referenced in the discussion section, several meta-analyses examining the outcomes of CSA vs. LSA have come to the same conclusions. Surgical site infections are also more common with the CSA technique, and this is consistent with additional meta-analyses and with the Michigan Bariatric Surgery Collaborative findings as well.
2- Some surgeons claim that a narrow anastomosis or stenosis is an important predictor of long term weight loss since Roux en Y gastric bypass is more of a restrictive procedure. Was the long term weight loss compared between the two groups? Would a greater long-term weight loss in CSA group have affected your "change of practice" decision?
While we only examined weight loss to 90 days in the current study, we have previously researched and published on this topic. Surg Endosc. 2011 July ; 25(7): 2164–2167 - Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study. In this study we examined the weight loss with the circular stapled anastomosis constructed with a 21-mm and subsequently with a 25-mm circular stapler. We found that at 3 and 5-years following surgery, the much smaller diameter anastomosis associated with the 21-mm stapler did not have an impact on long term weight loss. My own opinion is that there is a large 'sweet spot' so to speak for anastomotic caliber. There is definitely a point where an anastomosis is too small and a point where it is so big there can be little restriction. There is a range in between these 2 extremes where things work well and the amount of restriction is in part dependent on what patients eat, how they eat it, and other behaviors (such as drinking during meals, etc.)
3- Infection risk has been reduced in some practices by applying a wound protector at the stapler port. Was a wound protector utilized in CSA cases? .
Yes. In the methods section we describe the fact that "The circular stapler is placed in a well-lubricated plastic sleeve.... to avoid contact of the stapler itself with the subcutaneous tissues."
4- Do you believe that CSA is technically easier and more reproducible and more teachable, thus the wide adoption although the limitations of this technique are well illustrated?
I do believe the CSA technique is a bit easier to teach. I learned the CSA technique during my fellowship in 2001-02 in an era when not a lot of these procedures were being performed laparoscopically. That was the rationale at that time for constructing the anastomosis in this fashion. The transition from CSA to LSA for me was not difficult as I took this on about 10 years or more into my surgical practice and after more than 2,000 gastric bypass procedures. There is a little more work associated with creating an anastomosis with a LSA technique, but my personal opinion (as a surgeon who has trained 4 fellows since making the technique switch) is that LSA is reproducible and teachable. The learning curve might be a few more LSA repetitions, but not much more than that.
5- What kind of challenges would a surgical group face when a "change of practice' decision is made?
There is definitely angst associated with the change. Other than my dissatisfaction with the stenosis rate and the SSI rate associated with CSA, the patients did great. We were not having issues with anastomotic leaks or anything serious like that. It was a bit of a leap of faith to move out of my comfort zone and to tinker with something that was for the most part working well for over a decade. I watched a bunch of videos and talked to a lot of surgeons who did their anastomosis with an LSA technique. One of the things I observed was that everyone did their LSA a bit different. We made a few minor tweaks along the way before we settled on a consistent step by step approach to LSA. In the end, I settled on what I felt worked best for me.
Professor Jon Gould
Professor and Chief, General Surgery; Alonzo P. Walker Professor in
General Surgery, Medical College of Wisconsin, USA
To repair or not to repair the ventral hernia simultaneously during the bariatric surgery in morbid obese patients is a well debated topic. Opponents of simultaneous repair claim it to cause problems like hematoma, seroma, infection in short term and hernia recurrence in long term. A retrospective review of 106 patients who underwent simultaneous ventral hernia repair (VHR) during either RYGB or sleeve gastrectomy was performed in a single bariatric unit. They had a combination of open repair and laparoscopic repair as the study period was from 2007 up to 2015. They found that the wound related problems were more common in the open repair group. Majority of these patients had T2DM. Hematoma and seroma were more common in patients who had mesh used in the repair. Hernias recurred in 14.89% patients who had open repair compared to only 8.47% who had laparoscopic repair. Recurrence was more common in patients who had BMI >45, females and who had >5cm defect size. The authors concluded that synchronous VHR and bariatric surgery is feasible keeping the above factors in consideration.
Krivan, M. S., Giorga, A., Barreca, M., Jain, V. K., & Al-Taan, O. S. (2018). Concomitant ventral hernia repair and bariatric surgery: a retrospective analysis from a UK-based bariatric center. Surgical endoscopy, 1-6.
This interesting review of prospectively collected data of 1331 consecutive patients from a single center analyzes and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux-en-Y bypass (RYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric band (LAGB). Postoperative BMI and %EWL were compared at 1, 2 and 3 years. The mean %EWL was 77.9±24.4%, 50.8 ± 25.8% and 40.8± 25.9% at 2 years for RYGB, LSG and LAGB (P< .0001) respectively. At 1 year the odds ratio of lack of successful treatment effect of LSG Vs RYGB was 6.305 which increased significantly to 70.7 at 2 years. Similarly, the odds ratio of LAGB Vs RYGB of 36.552 at 1 year increased significantly to 128.1 at 2 years. The odds ratio for LAGB Vs LSG at 1 year was 5.791. This interestingly decreased to 1.8 at 2 years. This study emphasizes the heterogeneity in weight loss and lack of treatment effect among various bariatric procedures. They concluded that though LAGB has greatest rate of lack of successful treatment effect, the rate was stable over 3 years postoperatively compared to LSG which showed doubling in the rate of lack of successful treatment. RYGB fared best among the three bariatric procedure.
Azagury, D., Mokhtari, T. E., Garcia, L., Rosas, U. S., Garg, T., Rivas, H., & Morton, J. (2018). Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Surgery.
Robotic surgery brings a lot of attention. Not only surgeons, but also patients may see it as potentially beneficial. Initial experience suggested some advantages, especially for more complex procedures like revisional bariatric surgeries. Standard procedures, including gastric bypass may seem to be technically easier requiring less efforts from a surgeon, thus potentially reducing risk. Several studies showed relatively low rate of complications. Recent investigations comparing laparoscopic and robotic bariatric procedures indicated its safety, however did not show it to be better in terms of risks of complications. When compared to identical operation done laparoscopically, robotic operation takes longer time and is more expensive. Robotic surgery did show shorter hospital stay, lower readmission rate and reduced stricture formation. Despite of promising technical advances, overall outcomes of robotic surgery do not seem to be better than traditional laparoscopic approach.
Rogula, T., Koprivanac, M., Janik, M. R., Petrosky, J. A., Nowacki, A. S., Dombrowska, A., ... & Schauer, P. (2018). Does robotic Roux-en-Y gastric bypass provide outcome advantages over standard laparoscopic approaches?. Obesity surgery, 28(9), 2589-2596.
All doctors strive to excel in their respective field. What defines that? Sir Barry Jackson, the past Serjeant Surgeon to the Queen, the past President of The Royal College of Surgeons of England and also the past President of the Royal Society of Medicine describes the inherent qualities needed to define the surgeon to be an ''Excellent Surgeon''. Is it his speed or his technical skills? Is it boldness or flamboyance? Is it about making the judgement of when to operate or when not to operate? Is it calmness or erring to being a psychopath? Is it his knowledge or his operative results? Or, is it just being a good team player or having good communication skills? Is it one who reaches high office posts or one who drives a Rolls Royce? Or is it about following the rule - do unto others as you would have done unto yourself. The list goes on! And who is actually the right person to judge? Patients, relatives, nurses, junior doctors or colleagues.
Jackson, B. (2019). What Makes an Excellent Surgeon?. Obesity Surgery, 1-3.